Therapy or medication for anxiety: what the research shows

“My doctor said I could start on tablets or go to therapy. Or both. And now I’m sitting at home with a prescription in my handbag, and I don’t know what’s right.”

I hear a sentence like this more often than I would have expected. Someone has gathered their courage, gone to the doctor, said that anxiety has been choking them for months — and instead of one answer, they have been given a choice. A choice is a good thing, but when you are exhausted it can also be a burden. Especially if everyone you ask tells you something different: the neighbour swears by tablets, a friend says tablets are just a plaster, and online you find both, both of them very loud.

In this post I will try to give a clear summary of what research says about treating anxiety: what psychotherapy can do, what medication can do, when a combination makes sense, and what happens once treatment ends. But let me say one thing clearly at the outset: I am a therapist in training in marriage and family therapy, not a doctor. I don’t prescribe medication and I don’t give advice about it. Whether to take it, which one and for how long is something you decide together with your doctor. My aim is for you to walk into the surgery better prepared and with less shame.

First of all: both paths are legitimate

The “therapy or medication” debate often sounds in public like a dispute between two camps. In reality, professional guidelines on what helps with anxiety agree to a surprising degree: for most anxiety disorders, both psychotherapy (the most researched being cognitive behavioural therapy) and certain medications prescribed by a doctor are recommended as a first choice. The question is not which treatment is the “real” one, but what makes the most sense for you, now.

It is interesting what people themselves think about this. In 2013 the American psychologist Kathryn McHugh and her colleagues pooled studies in which people were asked which treatment they would prefer. Roughly three in four preferred psychological treatment to medication. This is not proof that therapy is better — but it does say that many people want to understand what is happening to them, not just for the symptoms to go away. In practice, though, the road to therapy is often longer and more expensive than the road to a prescription, so what people want and what actually happens are not always the same thing.

What psychotherapy can do

Cognitive behavioural therapy is by far the most researched treatment for anxiety. It teaches you to recognise the thoughts that inflate anxiety and to gradually approach what you avoid. It isn’t magic, but it is systematic: for panic attacks, social anxiety, generalised anxiety and obsessive-compulsive disorder it has clear research support.

But it is not the only one. In 2013 a German team led by Falk Leichsenring compared cognitive behavioural and psychodynamic therapy for social anxiety in a large study. Both helped, cognitive behavioural therapy somewhat more on certain measures, but the differences were smaller than supporters of either side might have expected. Approaches that focus more on relationships, such as relational family therapy, in which I am training, understand anxiety as something that was not born in a vacuum — but in a family, in relationships and in experiences that taught a person the world is not safe.

I have to be honest, though: researching psychotherapy is considerably harder than researching a tablet. You can’t give it “blind”, therapists differ from one another, and the relationship between therapist and client is part of the treatment. I wrote about this in Why therapy is harder to research than a tablet — and what that means for the evidence. So part of the reason there is most evidence for cognitive behavioural therapy is that it is the easiest to research — not necessarily that it is the only one that works.

What medication can do

For longer-lasting anxiety, doctors most often prescribe antidepressants from the group of selective serotonin reuptake inhibitors (SSRIs) or a related group. The name is misleading: they are not only for depression, and they are well researched for many anxiety disorders. They can be prescribed by your GP or a psychiatrist; with more complex difficulties it is right that a psychiatrist follows your care.

A few general things worth knowing before you talk to your doctor: the effect usually doesn’t show straight away, but after a few weeks; at the start there may be side effects, which often pass; and medication is not something you simply stop overnight. How this applies to you must be explained by a doctor who knows you — not a friend, not a forum, and not this post.

Medication does not “fix a chemistry” that was broken. The chemical imbalance story was a convenient explanation, but science has outgrown it — more in Chemical imbalance: the serotonin story that science outgrew. That doesn’t mean medication doesn’t work. It means it works differently from how it is often simplified: for many people it reduces the intensity of anxiety enough that they can move again, sleep, work and — importantly — take part in therapy.

What direct comparisons show

The most honest question is this: if we divide the same group of people into those who receive therapy and those who receive medication — who will be better off at the end? The Dutch researcher Pim Cuijpers and his colleagues gathered exactly such studies in 2013. For anxiety disorders, psychotherapy and medication turned out to be similarly effective on average. The exception was obsessive-compulsive disorder, where psychotherapy came out better in these comparisons.

Another large analysis, published in 2015 by Borwin Bandelow and colleagues, compared how much symptoms decreased from the start to the end of treatment, and found larger changes with medication. Experts don’t fully agree on how to read this difference — such measures are less reliable than direct comparisons, and studies of medication and of therapy are often designed differently. A fair summary is: both paths work, neither works for everyone, and the differences between them are smaller than the differences between individuals.

What happens when treatment ends

This is where a difference shows up that is often overlooked in the “therapy or medication” conversation. In 2000 an American team led by David Barlow compared cognitive behavioural therapy, a medication and their combination for panic disorder. During treatment itself, the paths were fairly evenly matched. But once treatment ended and people were followed for several more months, results were generally more lasting for those who had had therapy.

The explanation makes sense: therapy leaves behind something a person takes with them — understanding, skills, a different relationship with their own fear. Medication works while you take it. A review of studies published in 2017 by Neeltje Batelaan and colleagues showed that among people with anxiety disorders who stopped their medication after improving, anxiety returned more often than among those who continued taking it.

It is important to read this correctly. It doesn’t mean medication “doesn’t really work”. It means that the decision about when and how to end treatment with medication is very important — and that you make it together with your doctor, not alone. Stopping on your own can bring problems that are easily mistaken for anxiety coming back.

Combination: when two paths at once

What if you don’t choose, but take both? In 2014 Cuijpers and colleagues reviewed studies in which psychotherapy was added for people who were already taking medication. In depression and in some anxiety disorders, the added therapy improved outcomes. I wrote in more detail about why medication and therapy are not rivals in Antidepressants and therapy are not rivals: what the research says about combining them, so here just the essentials.

In practice I notice that a combination often helps when anxiety is so strong that a person can do nothing in therapy except survive the hour. Then medication prescribed by a doctor can turn the volume down enough for it to become possible to talk, think and try new things. Therapy then does what a tablet cannot: it looks for where the fear was learnt, and helps build something that lasts.

Benzodiazepines: particular caution

I need to mention sedatives from the benzodiazepine group in particular. They work quickly, so in acute distress people experience them as a rescue. But that very speed is also their trap: the body gets used to them, over time more is needed for the same effect, and on stopping, withdrawal symptoms can appear that closely resemble anxiety itself. That is why professional guidelines recommend using them only for a short time and under a doctor’s close supervision.

If you are already taking them, that is no reason for panic or shame, and certainly no reason to stop suddenly. But it is a good reason to talk to your doctor about a plan: for how long, what next, and how gradually. Some research suggests they can also interfere with the learning that exposure is based on, so it is good to be open about them with your therapist too.

Where you stand in the system also matters for the decision. In Slovenia an antidepressant can be prescribed by your GP, while the road to a clinical psychologist or psychiatrist runs through a referral and often a waiting list. Psychotherapy is most often self-funded. I described how these routes work and what you can do while waiting in Referral, waiting list or self-funded: how you actually get help here.

What a conversation about it might sound like

The conversation below is composed and not about a real person. I wrote it down because I hear it in various forms quite often.

“If I start on tablets, it means I can’t cope on my own.”
“Who told you that?”
“No one. My mum always said you just have to pull yourself together.”
“And did you pull yourself together?”
“For years.”
“Maybe the question isn’t whether you can cope on your own. Maybe it’s how much longer you want to keep coping on your own.”

The decision about medication is not only a medical one. Family beliefs often slip into it — that taking tablets is weakness, or, on the contrary, that talking about feelings is a waste of time. These beliefs are worth looking at before they make the decision for you. This is one of the moments when therapy and medicine complement each other well: the doctor judges what makes medical sense, and in therapy we look at everything the decision stirs up in you.

Exercise: prepare for the conversation with your doctor

An appointment is short, and anxiety can wipe out everything you meant to say. This exercise helps you arrive prepared. Take fifteen minutes for it today.

1. Describe your anxiety in three sentences. When it started, how often it comes and how it shows in your body. Be concrete: “I wake up at four with my heart pounding” says more than “I feel bad”.
2. Write down what it has taken from you. What you have stopped doing, where you no longer go, how you sleep, how things are at work and at home. This helps the doctor judge how severe the distress is.
3. List what you have already tried. Conversations, exercise, therapy, past medication and how it worked — even if you feel awkward about it.
4. Prepare your questions. For example: what do you recommend and why, when can I expect an effect, what should I watch out for, how will follow-up work, what if I want to end treatment at some point.
5. Say what you would like. If you would rather try therapy first, or if you are afraid of medication, say so. A good doctor will take your wishes into account in a shared decision and tell you when, in their judgement, it would not be wise to follow them.

Take the sheet with you; you can simply hand it to the doctor. You don’t have to say anything from memory.

Where the “therapy or medication” debate misses the point

Everything I have written is about averages. You are not an average. One person responds well to the first medication, another only to the third; for one person therapy changes their life, another realises after a year that they need a different therapist or a different approach. Research tells you where it makes sense to start, not where you will end up.

Sometimes the answer is neither. Anxiety can be a sign of a physical problem — with the thyroid or the heart, for instance — so a first check-up with a doctor always makes sense; I wrote about this in Panic or the heart? What to check with a doctor before starting therapy. And sometimes anxiety is an entirely reasonable response to circumstances that are not safe: violence at home, the threat of losing your job, a relationship in which you never know what will happen. Then you need not just treatment for a symptom, but a change in circumstances and support to carry it through. If you are experiencing violence, in Slovenia the SOS helpline for women and children victims of violence is available on 080 11 55, and in an emergency 113 or 112.

And finally: when anxiety is so severe that you can’t work, sleep or eat, or when it is joined by thoughts of not wanting to live, therapy is not the first step. Then you need a doctor or psychiatrist straight away — more in When you need a psychiatrist first: signs that therapy is not the first step. If you have suicidal thoughts, in Slovenia call the crisis line Klic v duševni stiski on 01 520 99 00 (7 pm to 7 am) or the Samaritans helpline on 116 123 (24 hours a day).

Whichever path you choose, it is worth knowing that it isn’t final. If something doesn’t work, you can go back and try something else. That is not failure but an ordinary part of treatment. People who struggle with anxiety over a long period — with generalised anxiety disorder, for example — often find their combination only on the second or third attempt. The same goes for intrusive thoughts that grow into obsessive-compulsive disorder: there the path is often specific and worth mapping out with a professional.

What to remember

• For anxiety disorders, psychotherapy and medication are similarly effective on average; neither path works for everyone.
• The effects of therapy are often more lasting after treatment ends, because it leaves behind understanding and skills.
• A combination makes sense especially with more severe anxiety, when medication makes it possible for therapy to get going at all.
• Benzodiazepines are for a short time and under a doctor’s supervision; don’t start or stop any medication on your own.
• You make the decision together with your doctor — and you can prepare for it, so that shame or a family belief doesn’t make it for you.